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Acceptance Application
Please fill out our Acceptance application form below so we can review your child’s needs.
Page
1
of 5
Parent / Guardian Information
First Name
*
Email address
*
Last Name
*
Phone Number
*
Relationship
*
Please select
Mother
Father
Foster Parent
Aunt
Uncle
Brother
Sister
Step Mother
Step Father
Grandmother
Grandfather
Address
*
City
*
State
*
Zip
*
Next
Patient Information
Patient First Name
*
Date of Birth
*
Patients Grade
*
Please select
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Patient Last Name
*
Patient Height
*
School Attending
*
Patient Weight
*
Back
Next
Assessment
Is the Patient Suicidal?
yes
no
Is there any verbal expressions of suicide?
yes
no
Is there any physical harm to self? (cutting, eating disorder, etc.)
yes
no
Any suicidal attempts?
yes
no
If the child went to the hospital for any of these, did the Dr. indicate that it was an actual suicide attempt or was it attention seeking behavior?
suicide attempt
attention seeking behavior
Is the patient violent with any other kids, siblings or property?
yes
no
If the answer to any of these questions is YES, please list the details.
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Next
Legal Standing
Has the patient been arrested?
yes
no
Is the patient on probation?
yes
no
Is there a court date?
If the answer to any of these questions is YES, please list the details.
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Next
Insurance Application
Does the patient have private insurance?
yes
no
Policy Holder / Insurance Information
Policy Holder Name
*
Policy Holder Phone Number
*
Insurance Provider Phone Number
*
Policy Holder State
*
Policy Holder Date of Birth
*
Insurance ID Number
*
Policy Holder employer
*
Insurance Provider
*
Insurance Group ID Number
*
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Send
This field should be left blank
ACCEPTANCE FORM
INSURANCE VERIFICATION
APPLY FOR FINANCING
PAYMENT
REGISTRATION
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